DMEPOS Providers Business Capabilities Survey
General Information
1.What is your company name?
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2. What is your name?
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First Name
Last Name
3. What is your email?
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example@example.com
4. What is your Tax ID Number (TIN)?
5. What Order Management System (OMS) does your organization utilizes (ex. Brightree)? If you do not use an OMS, please note "no".
6. Tomorrow Health orders will be sent to you through our web-based platform. Please list the names and email addresses of the individuals that manage your organization's order intake so we can grant them access to your organization's account on the platform. We encourage suppliers to have at least 2-5 users. (use + button to add multiple users)
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7. What is your company's phone number?
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Area Code
Phone Number
8. What is your company's fax number?
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Area Code
Phone Number
9. Please enter the addresses of your company's retail locations. Use the "+" button if there are multiple locations
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Insurance Coverage
1. Please place an "X" to indicate which insurance plans your company is contracted with (select all that apply). If you are in-network with other plans associated with the payor, please use the comment section to enter those specific plans.
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Commercial
Medicare
Medicare Advantage
Medicaid
Comments
Aetna
Anthem
AmeriHealth
Ambetter
Blue Cross Blue Shield
Cigna
Humana
Molina
Tricare
United Healthcare
Amerigroup
PA Health and Wellness
Keystone First
Carefirst
Healthnet
Highmark
Oscar Health plans
Geisinger Health Plan
2. If you accept insurance plans that are not noted above, please list those plans you are contracted with below.
3. Do you offer financial assistance, waiver programs or payment plan options for your customers?
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Yes
No
4. If yes, please list and describe the assistance / waiver programs you offer your patients.
5. Please list / describe other patient quality and assistance programs you offer your patients.(e.g. remote patient monitoring, respiratory therapist, etc.)
Product & Delivery Capabilities
1. Do you support delivery for urgent, same-day discharge orders (e.g. for items such as oxygen, walkers, commodes, etc.)?
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Yes
No
2. Does your organization have a phone number for urgent orders needed past 5:00 pm and weekend orders 9-5 PM?
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Area Code
Phone Number
3. Please check the product categories you are able to service urgently after-hours (ie. deliver same-day). You can add more categories in the "Other" section. If your organization does not process after-hours orders, please indicate so below.
We do not process urgent after-hours orders
Oxygen
Nebulizers
Walkers/Wheelchairs
Hospital Beds
Commodes
Other
4. Do you service pediatric equipment? If yes, please indicate which categories you service for the pediatric population. You can add additional categories/specific products in the "Other" section if not noted below.
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No, we do not service
CPAP / BiPAP
Mobility
Nutrition
Oxygen / Pediatric Flowmeter
Ventilators / High-Tech equipment
Apnea monitors / Phototherapy
Other
5. Please indicate the product categories for which you offer a sampling program for your customers.
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No, we do not offer a sampling program
Diabetic
Urology
Incontinence
Ostomy
Nutrition
Tracheostomy
Other
6. If you would like to add more information regarding your sampling program, please do so here.
7. Do you offer remote CPAP set-up services for your patients?
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Yes
No
8. Do you offer equipment repairs for products you supplied the patient?
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Yes
No
Other
9. If you answered yes in question 9, please share what product categories you offer repairs for.
10. To ensure Tomorrow Health sends you product brands you can service, please use the drop-down menu to indicate the product category and use the fill-in section to list which brands you carry by category.
11. Do you have delivery drivers for each of your retail locations that are able to assist with equipment assembly?
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Yes
No
Other
12. Do you drop-ship inventory commercially from each of your company's locations? (e.g. USPS, UPS, FedEx, etc.) If yes, please indicate whether you can ship to all of PA or your surrounding counties.
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No, we do not ship our products
Yes, we ship statewide and/or nationwide
Yes, we only ship to our surrounding counties
Other
13. Some DMEPOS providers maintain an onsite supply of equipment and supplies at servicing provider offices, post-acute settings, and hospitals - commonly known as supply closets or consignment. Does your organization have supply closets?
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Yes
No
Other
14. If you answered "yes" above, please indicate your urgent discharge capabilities for the supply closets you maintain. If you do not maintain a supply closet check "I do not maintain a supply closet".
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Same Day Supply Closet Capacity
Delivery to Hospital Same Day Capacity
Delivery to Home Same Day Capacity
Delivery during Business hours only (8 - 5PM/M-F)
Delivery via DropShip only
Oxygen Tanks
Oxygen Concentrator & Tanks
Nebulizers
Walker/ Rollator
Wheelchair
Hospital Bed
CPAP / BiPAP
Wound Care
I do not maintain a supply closet
15. If you answered yes above, please upload a spreadsheet that reflects your supply closet relationships for each of your company's individual retail locations.
Browse Files
Note: This file must be completed in Microsoft Excel.
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16. Are there are other details that you would like to share with us regarding your servicing capabilities for your organization?
Submit
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